Fillable SPOUSE OR DEPENDENT TUITION WAIVER APPLICATION Office of (Dickinson State University)

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SPOUSE OR DEPENDENT TUITION WAIVER APPLICATION Office of (Dickinson State University)

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SPOUSE OR DEPENDENT TUITION WAIVER APPLICATION
Office of Financial Aid, May Hall 209 701-483-2371
Eligibility is defined in the Spouse or Dependent Tuition Waiver Policy 820.001.007
Please complete, print, sign and return this application to the Office of Financial Aid by the appropriate deadline that falls
prior to the period in which your dependent will be utilizing the tuition program.
EMPLOYEE
INFORMATION
Name: Eligible employee EMPL ID#:
Campus Phone: Home Phone:
Home Address:
DEPENDENT
INFORMATION
Name: Student EMPL ID#: Date of Birth:
Student status for period being requested:
First time student Returning student Transfer student Graduate student
Personal Enrichment (Non-Degree seeking)
TUITION
PROGRAM
PRIORITY
APPLICATION
DATES
First Application Renewal Application
April 15; for entire academic year or summer only
September 15; for spring semester only
SEMESTERS
REQUESTED
Fall semester
Year
Spring semester
Year
Summer semester
Year
DOCUMENTATION
The Eligible Employee must provide the University with documentation of marital status or dependency.
Ex Examples of documentation may include but are not limited to:
Marriage certificate
Birth certificate
Documentation from the court
First two pages of most recent signed and submitted income tax return
SPOUSE OR DEPENDENT TUITION WAIVER APPLICATION
Office of Financial Aid, May Hall 209 701-483-2371
EMPLOYEE
CERTIFICATION
OF DEPENDENT
STATUS
I certify that:
1. This student is my spouse or dependent and I have provided documentation as required in the Spouse or
Dependent Tuition Waiver Policy; and
2. This student is my (select one):
spouse
biological child;
child for whom I am the legal guardian as appointed by the court
adopted child; or
child of an eligible spouse;
3. I have read the Dickinson State University Spouse or Dependent Tuition Waiver Policy and understand
how it pertains to me and my spouse or dependent; and
4. The information I have provided on this form is true to the best of my knowledge and I understand that
misrepresentation of any statement on this form is cause for cancellation of the tuition benefit; and
5. I agree to notify the Office of Financial Aid in writing of any changes in marital status or dependency
status that occur during the academic year; and
6. I understand that this waiver will be approved upon meeting the criteria; that the value of this waiver is
taxable income to the employee for graduate level courses taken by the spouse or dependent and that
the applicable payroll taxes will be deducted from the employee’s paychecks during each semester; and
the wavier amount received and the spouse or dependent will be disclosed on the employee’s annual
benefit statement.
Employee Signature ____________________________________________ Date __________
Spouse/Dependent Signature ______________________________________ Date ____________
To properly certify spouse/dependent eligibility, documentation is required to be submitted with this
application. If you have not already provided it, please submit the appropriate legal documentation to
support the dependency relationship in #2 above. If you have any questions, please contact the Office of
Financial Aid at 701-483-2371.
ELIGIBILITY
CERTIFICATION
To be completed by
FA and HR
HR Confirm Benefited Employee: ____________________________ ____________(Date)
FA Approve Benefit: ____________________________ ____________ (Date)
FA Denied Benefit: ____________________________ ____________ (Date)
Reason:
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SPOUSE OR DEPENDENT TUITION WAIVER APPLICATION Office of (Dickinson State University)

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Completed 19 August 2020

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